MEDICARE: KIMBERLEY GRAHAM JARUTOWICZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-13-12822	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-13-12822	OTHER	TX	BCBA CERTIFICATE NUMBER

General Provider Information

NPI Number	:	1386087930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLEY GRAHAM JARUTOWICZ BCBA

Provider Business Mailing Address
First Line	:	1438 COUNTY ROAD 314
Second Line	:
City	:	FLORESVILLE
State	:	TX
Zip	:	78114-3340
Country	:	US
Telephone Number	:	210-289-7686
Fax Number	:	186-640-3798

Provider Business Practice Location Address
First Line	:	2525 LADD ST BLDG 3850
Second Line	:
City	:	LACKLAND A F B
State	:	TX
Zip	:	78236-5308
Country	:	US
Telephone Number	:	210-289-7686
Fax Number	:	186-640-3798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2013
Last Update Date	:	04/14/2013

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